Acute Management in the ED
When a patient presents with suspected myocarditis you need to ensure you manage the following:
Supportive care is the initial treatment for patients with myocarditis. A rapid assessment of the airway, breathing and circulation should be made. Some patients may require resuscitation with urgent initiation of invasive ventilation whilst others may not require any supplemental oxygen and are haemodynamically stable on initial presentation.
Adequate perfusion pressures should be maintained which may require maximising preload with cautious fluid administration and/or the use of vasopressors and inotropes to maximise cardiac function. This will mandate invasive monitoring and central venous access.
Heart failure should be treated following conventional guidelines. In the acute setting, this may require diuretics, nitrates and non-invasive ventilation; in the longer term, ACE inhibitors have an important role in management.
Cardiac arrhythmias should be treated promptly to reduce the increased myocardial demand and treat systemic hypoperfusion that occurs as a consequence of the arrhythmia.
The ECG shows a broad complex tachycardia.
Other factors or co-morbidities which may exacerbate physiological compromise, (e.g. anaemia, intercurrent infection and poor glycaemic control) should be promptly identified and treated.
Some patients may not maintain an adequate cardiac output despite these measures and the use of intra-aortic balloon pump or extra-corporeal membrane oxygenation may be required.